Source Citation

Abstract

Objective

To evaluate the effectiveness of a postal screening questionnaire with selective follow-up
and intervention in reducing mortality and morbidity of older persons living at home.

Design

3-year randomized, single-blind, controlled trial.

Setting

A general practice in South Wales, United Kingdom.

Patients

725 noninstitutionalized patients aged ≥ 65 years (mean age 73 y) registered with
a general practice in Cardiff. 47 patients (6%) were lost to follow-up.

Intervention

369 patients were randomized by household to the intervention group that involved
problem identification using an annual self-reporting postal questionnaire to identify
changes in functional ability for everyday activities. Patients who reported problems
were visited by a nurse, who provided practical advice, health education, and, if
needed, a referral to the general practitioner or community services. 356 patients
were randomized to the control group, which had no questionnaire and no contact with
the study nurse.

Main outcome measures

Mortality, use of hospital and community services, admissions to institutional care,
number of contacts with general practitioners, and quality of life.

Main results

Fewer patients in the intervention group died during a 3-year follow-up than did patients
in the control group (P = 0.05) (Table). The groups did not differ for number of hospitalizations, but the
mean length of stay was shorter among patients aged between 65 and 74 years in the
intervention group (11 vs 15 d, 95% CI for the 4 d difference, 2 to 8 d, P < 0.01). Most patients who were admitted to long-term institutional care were
≥ 75 years of age; slightly fewer intervention group patients were institutionalized
then were control group patients (8% vs 14%, CI for the 6% difference -0.9 to 13,
{ P = 0.09}*). The intervention group had fewer home visits by the general practitioner
or hospital specialists but had more office visits to the general practitioner when
compared with the control group. Quality of life measures (general health status,
life satisfaction, and functional incapacity) among 3-year survivors did not differ.

Conclusions

A case-finding and surveillance program for elderly people living at home was effective
in reducing mortality, length of hospital stay, number of patients institutionalized,
and number of home visits by physicians.

Table. Case-finding and surveillance vs control in older noninstitutionalized patients at
3 months†

Outcome

Intervention

Control

RRR (95% CI)

NNT (CI)

Death

18%

24%

25% (0.3 to 43)

17 (8 to 1695)

†Abbreviations defined in Glossary; RRR, NNT and CI calculated from data in article.

Commentary

Britain, long a pioneer in geriatric care, has out of necessity mastered the art of
doing more for less. In the study by Pathy and colleagues, a low-intensity surveillance
and home-assessment strategy was used to improve the outcomes for elderly persons
living in the community. Surprisingly, their patients did not consume more medical
or social services, implying that resources were well matched to actual needs.

Several issues thwart direct extrapolation of these results to the United States.
Similar studies in this country have not produced comparable benefit (1, 2). Poor patient targeting (e.g., self-referral of the minimally disabled) and fragmentation
of services for the elderly may account for this disparity. Few data are provided
on patient characteristics, and, despite randomization, we cannot presume that the
groups were comparable in baseline risk. Few details are provided about the process
of care; the "black box" approach makes the intervention difficult to replicate.

Despite these caveats, several recommendations can be made. Primary care physicians
serving older patients should consider low-cost questionnaires for functional screening
(perhaps these can be distributed in the waiting room rather than by mail). Functional
decline should be recognized as a strong risk factor for death and morbidity (3). Patients reporting significant functional decline merit thorough evaluation and,
if needed, referral to a nurse or social worker with geriatric case-management experience.